The Challenge to Psychoanalysis and Psychotherapy

France, Part 1

A brief reminder of the propagation of psychoanalysis in France after the Second World War
In those times, after the Second World War, while one was becoming a psychiatrist, one wanted to be a psychoanalyst. In France, until the 1970s, it was through psychoanalysis that one entered the field of psychotherapy. Since the 1980s, psychiatrists and psychologists who undertake a personal psychoanalysis do not all want to become psychoanalysts; they do not necessarily apply to the training institutes which belong to the International Psychoanalytic Association (IPA). Young psychiatrists undertake psychotherapies which are reimbursed by the social security system. Sometimes, they carry out the training offered by the psychoanalytic institutes to improve their practice. In fact, their future consultants do not easily accept the strictness of the psychoanalytic method and wish to content themselves with brief psychotherapies.

In France, as elsewhere, a genuine analytic cure requires more than three sessions a week. These sessions should last at least 45 minutes. The length of the analysis cannot be foretold. At present, analyses tend to last longer, and a total duration of over five years becomes the usual rule. The indications for analysis were reserved for true neuroses which resulted in the neurotic manifestations of transference, mainly in those around 30 years old who were able to express verbally elaborated thoughts and to benefit from a cure that was aimed at enabling them to ‘work and love’. More strictly speaking, when he wanted to express the necessity to work on the distortions of the ego functions, Freud wrote: ‘wo es war, so I ich werden’. This meant that it was necessary to work on the transferential aspects of child neurosis and, through the analysis of defence mechanisms, to be able to reconstruct the repressed past of childhood.

Today, symptomatic neuroses are well enough treated by well-adjusted chemotherapies—and this is often what general practitioners are able to do. These neuroses do not end up in the psychiatrist’s office unless they are associated with depression or with a deterioration in the socio-affective realm. But this specialist knows how useful antidepressive medications are in these cases and he often contents himself with prescribing these drugs while recommending his patient to undergo a simple psychotherapy.

Therefore, analyses are undertaken either in individuals who are familiar with analysis, particularly if there are family or friendly relations, or in subjects whose symptomatology is poor but whose socio-professional success hides deep narcissistic difficulties. These are mediocre indications for psychoanalysis and they show how important the severity of the ‘pathology of normality’ is.

The family situation of these patients is often inextricably confused and psychoanalysis is asked to give solutions which it could not find by itself. Today, the psychoanalyst seldom has patients under 40 years old. But here, experience has shown that age, notwithstanding the psychic rigidity it entails, is not a major drawback. Indeed, the elderly person may reconsider his or her past in order to better understand it. He or she may reconstruct his or her adolescence, of which he or she speaks so easily, without knowing its true origin, and thus recover peace of mind.

Some behaviours, like homosexuality, can no longer be called perversions. They are variations of sexual behaviours which should not call for any correction.

Who is an analyst?
As has been the case in the United States for the past 20 years or so, psychoanalysts have mainly a psychotherapeutic role. But the increase in number, with no control, of those who quote Lacan as their authority and who ‘proclaim themselves’ psychoanalysts, leads to the fact that their atypical behaviour—which involves, in particular, extremely brief sessions—tends to reinforce in the public mind of the image of psychoanalysis itself, in which the patient reclines on a couch in front of a silent psychoanalyst. This tends to heighten distrust of real psychoanalysts.

In France, psychoanalysts’ long training, which, in general, lasts ten years in the institutes affiliated with the IPA, is why these people accede late to the title of psychoanalyst. Their theoretical and practical training includes supervised cures. Since few patients agree to submit themselves to this protocol, students of institutes are led to take difficult patients into supervised analysis—those who suffer from borderline states, with severe narcissistic disturbances. These patients usually obtain little benefit from these analyses, which are necessarily disappointing, if only because of their normality, which is obtained at the price of important narcissistic wounds, and often minor but burdensome sexual disturbances.

Therefore, the risk is that psychoanalysis may go through a parthenogenetic line: patients could claim themselves to be psychoanalysts by evading the hardships of selection and of institutional training. One wonders therefore if the psychoanalytic profession should be regulated.
Freud thought that the psychoanalyst’s profession was as difficult as politics or being a parent. In the last part of his life he advocated the creation of psychoanalytic training institutes independent of the universities, mainly the medical schools, where psychoanalysis would be transmitted while future analysts would become familiar with psychopathology and deepen their knowledge in the realm of the human sciences and the culture. It is difficult to see how, in France at least, the state would guarantee the professional value of those whose training essentially requires a psychoanalysis—in other words, the existence of a dependence relationship. Of course, the psychoanalytic training institutes are able to assess the candidates’ progress. Increasingly, the training (personal) analyst does not intervene in the assessment, which must be performed by a group of competent and experienced appraisers. The state could not endorse such a training. How would it separate the wheat from the chaff and would it trust only those training institutes which belong to the IPA founded by Freud in 19087 But, for the public, such a membership remains a real guarantee.

The French government is certainly not ready to recognize a statute for psychoanalysts, if only because the latter would increase the financial difficulties of the Social Security—which now reimburses sessions by psychiatrists as if these sessions were medical acts performed by specialists. But it is probable that a statute for psychotherapists will come from European directives (such a statute exists in the Scandinavian countries and Germany and was recently created in Italy). Then the issue of the acknowledgement of psychoanalytic societies will pose difficult problems and will lead to numerous conflicts, knowing the proliferation of groups who appeal to the Lacanian heritage.

The assessment of the results of psychoanalysis
It is quite understandable that the various agencies of the French Social Security system, which reimburse acts by doctors performing analysis want to compare their results with those of other psychotherapies.

Whether one wants it or not, brief or short psychotherapies are inspired by the study of the psychoanalytic relationship, even if they do not aim at the basic interpretation of the transference which evolves therein. It is true that other forms of psychotherapy have proved themselves useful—this is the case for some behavioural therapies which can change neurotic symptoms. So-called cognitive psychotherapies are actually therapies which aim at changing behaviour through sound suggestions and the study of the life programme.

The psychoanalytic version of psychodrama developed first in France and plays a very positive role in very inhibited adolescents and in young individuals with psychosis.

It is difficult to assess group analytic psychotherapies since in our country, and, most typically, in California, their practice is encumbered by weekend ‘therapeutic seminars’ where all sorts of activities, which depend mainly on sexuality, are put into play. Nevertheless, it is true that certain group analytic psychotherapies, especially in children and adolescents, prove themselves particularly efficient.

Finally, one is familiar with the spread of systemic theories concerning family. Systemists claim they can achieve extremely brief cures. It was possible, little by little, to consider that certain elements of systemic cures could be of help, mainly in children, when very useful consultations at long intervals are offered, in particular if one aims at working on the tree of life and at bringing to light the weight of intergenerational transmission.

Generally speaking, it is difficult to make a scientific assessment of the results of analysis. One would need to be able to take into account not only the disappearance of symptoms and the well-being which results but also the better ‘capacity to work and love’, which means that the person who benefited from an analysis is more efficient in his or her work and his or her social life, that he or she conveys solid values to his or her family and that he or she is no longer a social invalid who takes rest leaves and goes to rest homes but is an adult, conscious of his or her responsibilities as a citizen and as a mother or father.

Nevertheless, empirical studies based on the assessment of brief psychotherapeutic cures show that these lead to symptomatic improvements that are as important as those occurring after long analyses. Today, the tendency is to say that the technique which is used is less important than the psychotherapist’s experience.

Child and adolescent analysis
For children and adolescents, psychoanalysis is seldom applied in France. One implements shorter and more varied psychotherapies. The assessment of their results depends on the pathology involved and the therapist’s experience, which is often very insufficient. He often deals with children, for lack of better clients.

However, for the past fifteen years or so one field of application has been particularly fruitful: children under 30 months of age. Their disturbances can be understood through the study of the interactions between them and their parents. The predictive value of these disturbances seems certain. Brief mother-baby, or, preferably, parents-baby, psychotherapies are unquestionably very profitable.

The field of extension of therapeutic psychoanalysis
The development of the psychosomatic understanding of medicine depends undeniably on the work of certain psychoanalysts. The school of Paris has shown the importance of essential, ‘white’ depression in such cases. One must in any case understand the emotional approach of mental life, which corresponds more or less to what the members of this school have called ‘operative thinking’.

This is an essential model because the development of modern medicine, with its sophisticated means of investigation and its complex therapeutic techniques, requires psychological support, whose importance we will only evoke here.

Consider, for example, situations where parents learn early in the mother’s pregnancy that their child to come has a handicap and this handicap must be announced at birth. These are mainly situations where the data of the genetic map would foretell the appearance of a disease. These are cases where unconscious guilt feelings are magnified and play a painful role in the evolution of the disease. It has been said that psychoanalysts made parents of autistic children feel guilty. Probably, unfortunate words have been uttered by certain individuals who claim to be analysts, although analytical theory and practice show that the occurrence of a ‘retro-stated’ accident points to the importance of a previous event to which this accident gives meaning.

People who suffer from AIDS know that they have to die. One must nevertheless help them confront life. Here there exists a particular problem: that of young women who learn at the time of their pregnancy that they are infected with the virus or, knowing they are HIV positive, still want to have a child. They learn that their children have a 30 per cent chance of having AIDS and that they will probably die early. One must support them on this difficult road.

It seems to be accepted that analysts may help traumatized populations. Representatives of non-governmental organizations know that to recognize the existence of disturbances following long after the stress (PTSD, or post-traumatic stress disorders) is only a way to satisfy a need for classification. This syndrome takes up very different expressions, which require one to take into consideration the indignity and guilt which is felt. It is what Alexandre Minkowski (1994) shows wonderfully. A convert to psychoanalysis, this paediatrician writes: ‘Having reached 78, I found out that my apprenticeship was still not finished: I now attend children’s school.’ But a few lines later, the same ‘Minko’ reminds us that ‘these young victims of Bangladesh, Cambodia, Bosnia, Croatia, Rwanda, possess tremendous capacities of recovery, as soon as adequate aid is brought to them’.

Psychoanalysis brings a certain capacity for identification or, rather, for empathy, which enables one to act without believing in the omnipotence of action. It brings a knowledge of the necessities of the time in order to enable the traumatized populations to counter-identify with those who pretend to show them the true way, and so forth.

The clinical situation
As noted above, clear-cut neuroses have disappeared from the everyday clinical repertoire and neurotic symptoms have lost their meaning because they are approached in a purely descriptive and behavioural way as in The American Psychiatric Association’s Diagnostic and Statistical Manuals. The description of the borderline states, for example, overlooks the understanding of the importance of the fragility of narcissistic investments in these cases. This is only an example to show that descriptions which have the obvious advantage of allowing comparative therapeutic trials do not give any information on the organization of the pathological processes, such as psychoanalysis offers to do methodologically.

This type of classification has another drawback: it satisfies the concerns of all those who want to strike psychiatry out of the field of medical practice through the transformation of mental illness into a simple handicap without any evolution. One can see a clear example of this in autism and child psychoses. Thus, the word psychosis has surreptitiously disappeared from the classification catalogue; autism and pervasive disorders are the only terms mentioned. The word psychosis is not referenced or considered as descriptive any longer. Therefore, parents of this type of child hope that it will be sufficient to occupy and ‘train’ them.

Psychoanalysis offers a coherent psychopathological version of the symptoms that are observed. We do not know any version that is more logical, and we believe that it represents a school which, from this point of view, preserves all its merits.

The psychoanalytic practice
During the years that followed the Second World War, psychoanalysts were described as therapists of rich people and idle women. The development of social security system and insurance allowed other types of practice. Nevertheless, the establishment of methods of control, quite necessary in such situations of course, threatens to spoil the purity of the process and of the cure’s setting.

Likewise, the development of community psychiatry has allowed the introduction of psychoanalysis in the public services. Psychoanalysts play a major role in these situations, although this role is sometimes ambiguous when they refuse to take a direct part in the clinical or therapeutic work in a supervisory role.

For the child and the adolescent, psychoanalysts have devised many forms of psychotherapy. They often hastily claim psychoanalytic practice as their authority in its applications to the child. The future of these forms of psychotherapeutic action will not be ensured without a thorough evaluation and before innovative forms of action are conceived.

The critique of psychoanalysis
The history of the psychoanalytic movement and the adulterations of the process that this movement was careful to define, mainly concerning candidates, contributes to the possibility of the formulation of criticisms. A great number of these spring from dishonesty. One would prefer not to regret the intervention of public authorities when the selection of candidates cannot depend on methods tested in the university, but it is difficult to think that control by public authorities could regulate the practice of training analysis.

Criticisms bear also on the length of the cure, its uncertainties, its cost and the investment it demands. We will see that the extension of its field of action can only make one less demanding in this respect. It is true also that the success of pharmacology deprives psychoanalysis of its best indications—the relatively moderate symptomatic neuroses.

Finally, we will only mention the other theories of mental functioning and its pathology. They claim to be under the authority of the study of family systems, cognitivism, the study of body states, and so on.

Therefore, the large avenues which remain open to psychoanalysis will be examined mainly in the field of health, but the accomplishments of its applications should not be forgotten.

The psychoanalyst in the field of health
Psychoanalysis is still practised on a large scale, but many of those for whom psychoanalysis would be recommended reject it because of its length and uncertainties. Nevertheless, the indications of the cure have become greatly extended. First, it is no longer restricted to the young. On the other hand, its field of action, restricted by the success of chemotherapy in neuroses, goes well beyond this type of indication. Psychoanalysts treat cases of psychosis or pre-psychosis, perversions and psychopathy. But the cures become necessarily longer. It becomes necessary to introduce technical alternatives. One must, therefore, take into account these different parameters in order to try to foresee the future of the practice of psychoanalytic therapy. Those who would benefit from it want to feel better immediately. Their impatience is understandable. Focal and brief psychotherapies have been proposed in psychoanalytic institutions.

Other techniques claim to be very different because they rely on body expression or because they aim to change behaviour. Psychoanalysts have every motive to understand the way they function. The role these experiences played in the evolution of certain group techniques is well known, as is the fact that some of them use psychodrama as their means of expression.

We believe that the deciphering of the transgenerational mandate allows us to understand the role of the infantile conflicts that a patient’s parents have experienced (Lebovici 1993).

The systemists have proposed family treatments. Some psychoanalysts use their discoveries and consider that certain family approaches are of great interest (Lebovici 1993).

The therapeutic consultations
In child and adult psychiatry empathic encounters make the most of the interpersonal situation and of what is known of intrapersonal conflicts and use affect-bearing metaphors, and the representations which the latter evoke, to give a mutative value to infrequent consultations. This is a solution which seems more profitable than psychotherapies with no ending, which exhaust psychotherapists. Under certain conditions, the analyst may carefully show to his patient a videotape document taken with his consent and bring him to take a position on what he sees he has done and said (Lebovici 1986).

The psychoanalyst and the institutions
In psychiatry, psychoanalysts play a major role in the trials of what has been unfortunately called ‘institutional psychoanalysis’ since they are near the health-care professionals, families and patients (Racamier 1983). It is in these conditions of teamwork that a new fashion is beginning to develop: the fashion of co-therapies, which combine psychoanalytic psychotherapies, more or less brief, with behavioural or so-called cognitive approaches or hypnotherapy—mainly in its Ericksonian form, body approaches—not to mention group therapies.

Such practices are justified in the mind of those who recommend them because classical psychoanalysis cannot be applied in a hospital setting. It is therefore necessary to develop brief psychoanalytic psychotherapies, or even very brief therapies, focusing on one disorder. Other approaches can also be useful, so why not sum their possible effects? Also, co-morbidity is a fashionable notion that answers well to these mixed, or even ambiguous, indications. Finally, isn’t it an opportunity (not very scientific in my opinion) to compare the results of these various therapeutic approaches?

The psychoanalyst and illness
Psychosomatic medicine has been transformed by the contributions of psychoanalysis. It is probable that its contributions can still have important consequences in the economy of health because of the reduction of expenses which it can foster in case of chronic disease. The theoretical ideas suggested in France concerning the role of operative thinking and essential depression (Marty 1980), and in the United States concerning alexithymia, will continue to be of great interest.

The psychoanalyst’s presence in the hospital is increasingly called for in various departments, mainly in those treating adults and children with severe, acute and chronic conditions. They can help doctors and care-givers to better understand the needs of these people, to accompany them in cases of terminal illness, etc.

The psychoanalyst and early interactions
It seems interesting for us to consider further the part that psychoanalysts have taken in this new clinical, therapeutic and preventive approach. We will thus be led to address again the question of the future of psychoanalytic theory.

We must acknowledge our debt to the psychoanalysts who have insisted on the importance of social ties, confirmed that the description of bonding does not prevent one from emphasising the initial dependence of the new-born on maternal care and show that the real baby also belongs to the imaginary and fantasmatic world of its mother and that it is an active partner in the development of the interactions.

Nevertheless, many of these psychoanalysts, caring little for the difference between attachment and dependence and the possible opposition between the notion of interaction and that of pleasure and object hallucination which stems from the reactivation of the mnesic traces of gratification experiences and the coming into play of the auto-erotic zones, have carelessly let a rift deepen between their psychoanalytic practice and their contribution to the description of early interactions. In any case, this is a criticism by Sylvia Brody (1981) that I agree with.

Probably, Freud made direct observations in his attempt to reconstruct the psychic life of the baby. Later, Anna Freud and the American school of analytic psychology, represented mainly by the Child Study Center at Yale University, have shown its importance (Freud 1958; Kris 1950). The issue was mainly to show the importance of development and the baby’s extended dependency upon its environment.

The theories developed by certain post-Freudian psychoanalysts are more compatible with the study of early interactions. This is the case of Hermann, in The Filial Instinct, when he describes the clinging attitudes of the filial instinct: they are analogous to what is observed in the monkey who clings to the mammary hair of the adult. Winnicott (1965), on the other hand, has always described the object of the instincts as an object both real and internal: the breast is part of the baby. This author beautifully describes these situations with the help of vivid metaphors, which one must sometimes be wary of even though they carry a rich message: isn’t it the case concerning the transitional object, the mirror phenomenon, where the baby sees itself in its mother’s pupils? Finally, Mahler (1968), when she describes the individuation-separation
process, refers to behaviours observed in the relationship between the baby and the mother and to the origin of the self and object representation.

Some psychoanalysts, mainly French, have determinedly opposed the influence of direct observation of the child on the reconstruction of its mental life, and question the validity of history as opposed to structure. Pontalis states that one is not in the mental room of the unconscious: Paradoxically, it is child psychoanalysis that should deliver us more radically than adult psychoanalysis from the archaic illusion . . . . The lesson is important and it is twofold. First, by remaining on the look-out of what is going on in the children’s room—whether one remains at the door or steps inside—one takes a great risk of hearing only the sound of one’s own inner discourse. Then and foremost, the fantasy of the origins which underlies the analyst’s quest as well as it incites, let us note, the child’s quest, leads, step by step, on an almost irresistible regressive slope, to fold the originary back onto the origin, in order to embody, in the end, the latter in a reality Whether this reality is conceived as material—’the early environment’—or as psychic—’the archaic fantasies’—doesn’t change the matter.

Green (1979) makes a distinction between the scientist aspect of psychoanalysis and its hermeneutic version. He vigorously attacks developmental perspectives, likening them to medical views which are inevitably ‘orthogenic’—even if they rest upon the wish to give care. ‘Developmental’ psychoanalysis has not theorized ‘Freud’s child’, it has only made it na”ive hagiography. Hence the vigorous criticisms which he hopes to administer to direct observation by psychoanalysts. He opposes the real child of psychoanalysis the child of its constructed historical truth—to the real child of psychology. ‘The Freudian model of the work on dream has enabled psychoanalysis,’ says Green, ‘to identify the child’s desire. The child fits into psychoanalytic theory the same way as fantasy, transference, or symptom do’. When (later), the last time for the building of theory, Freud addresses infantile sexuality, he doesn’t observe it or content himself with observing it, he builds, at the same time, the hypothesis of the unobservable. And, mainly, he introduces discontinuity, which is essential for human sexuality and is present from the origins (repressed or made latent) then being reborn in full bloom—(apparent) life and death, rebirth.